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Maycon de Moura Reboredo, Diane Michela Nery Henrique, Ruiter de Souza Faria,
Alfredo Chaoubah, Marcus Gomes Bastos, and Rogério Baumgratz de Paula
Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia, NIEPEN, IMEPEN Foundation (Instituto Mineiro de
Estudos e Pesquisas em Nefrologia), Federal University of Juiz de Fora, Juiz de Fora, Brazil
Abstract: Hypertension and cardiovascular diseases are After the intervention phase, the 6MWT distance increased
highly prevalent in hemodialysis patients and are associ- from 508.7 ⫾ 91.9 m to 554.9 ⫾ 105.8 m (P = 0.001), sys-
ated with the reduction of physical functioning and quality tolic and diastolic blood pressure decreased respectively
of life. We evaluated the effects of supervised aerobic from 150.6 ⫾ 18.4 mm Hg to 143.5 ⫾ 14.7 mm Hg and from
exercise training on physical functioning, blood pressure, 94.6 ⫾ 10.5 mm Hg to 91.4 ⫾ 9.7 mm Hg (P < 0.05), while
quality of life, and laboratory data in hemodialysis patients. hemoglobin levels increased from 10.8 ⫾ 1.2 g/dL to
Fourteen patients were evaluated at the beginning and 11.6 ⫾ 0.8 g/dL (P < 0.05). Moreover, there was a signifi-
after 12 weeks of stretching exercises (control phase) and cant increase in the physical functioning, social functioning,
at the end of 12 weeks of aerobic exercise training per- and mental health dimensions of the SF-36. Aerobic
formed during hemodialysis sessions (intervention phase). exercise training during hemodialysis increased physical
Patients underwent a 6-min walking test (6MWT), 24-h functioning, reduced blood pressure levels, and improved
ambulatory blood pressure monitoring, a Medical Out- the control of anemia and quality of life in patients
comes Study 36—Item Short-Form Health Survey (SF-36) with end-stage renal disease. Key Words: Exercise—
quality of life questionnaire, and blood sample collections. Hemodialysis—Blood pressure—Quality of life.
In patients with end-stage renal disease (ESRD) other alterations present in ESRD, result in a reduc-
on hemodialysis (HD), cardiovascular diseases rep- tion in physical functioning and have a negative
resent the principal cause of morbidity and mortality impact on the quality of life of patients on dialysis
(1). Among these, hypertension is highly prevalent in treatment (4–6). In conjunction, the physical and
patients with ESRD, sometimes causing the disease, psychological alterations of these patients induce a
sometimes complicating it (2,3). At the beginning of sedentary lifestyle, and the attempt to change this
HD treatment, approximately 80–90% of the patients behavior in ESRD is relatively recent in Brazil,
are hypertensive, and, after this initial period, nearly where the dialysis centers rarely offer an exercise
60% continue to present elevated blood pressure program during HD to these patients.
levels (3). In this study, we evaluated the effects of supervised
Cardiovascular diseases, as well as endocrine– aerobic exercise training on physical functioning,
metabolic, osteomyoarticular complications and blood pressure, quality of life, and laboratory data in
patients with ESRD subjected to HD.
586
aor_929 586..593
AEROBIC EXERCISE TRAINING DURING HEMODIALYSIS 587
University Hospital of the Federal University of Juiz ABPM, SF-36 interview, and blood samples
de Fora. collections.
A total of 18 patients, 7 men and 11 women, were
included, with a mean age of 47.6 ⫾ 11.4 years, on
HD for 77.2 ⫾ 50.1 months, who were not on a Six-minute walk test
regular exercise program for at least 6 months. The The analysis of physical functioning was performed
exclusion criteria were unstable angina, uncontrolled by 6MWT during the nondialysis day following the
arrhythmia, uncompensated heart failure, uncon- recommendations of the American Thoracic Society
trolled hypertension with systolic blood pressure (8). Patients were instructed to walk as fast as pos-
(SBP) of ⱖ200 mm Hg and/or diastolic blood pres- sible during the 6 min on a flat 30-m track, and the
sure (DBP) of ⱖ120 mm Hg, uncontrolled diabetes distance walked was recorded in meters. Patients
mellitus, severe pneumopathies, acute systemic in- were allowed to stop and rest during the test but were
fection, severe renal osteodystrophy, as well as instructed to resume walking as soon as they felt able
neurological and musculoskeletal disturbances and to do so. The two tests were completed on the same
osteoarticular incapacity. day, with an interval of 30 min between each, regis-
The study protocol was approved by the Research tering the greatest distance obtained. At the end of
Ethics Committee of the Federal University of Juiz the test, the level of perceived exertion was obtained
de Fora, and all patients signed an informed consent. by Borg scale (9).
with values from 0 (highly compromised) to 100 (no activity, significant alterations in heart rate, SBP or
compromise). DBP, and fatigue of the lower limbs.
Statistical analysis
Laboratory data
Values were expressed as mean and standard
Hemoglobin, adequacy of dialysis (Kt/V), creati-
deviations (SD). The general linear model repeated
nine, phosphorus, potassium, calcium, albumin, total
measures analysis of variance was used for compari-
cholesterol, high-density lipoprotein, low-density
son of study measures with means comparisons per-
lipoprotein (LDL), and triglycerides were drawn
formed by using the least significant difference post
before the first HD session of the week and measured
hoc test. A P value of <0.05 was considered statisti-
at the Central Laboratory of the University Hospital.
cally significant. All statistical analyses were per-
The Kt/V was calculated by using this equation:
formed by using SPSS 11.0 for Windows (SPSS, Inc.,
Kt V = 2.2 − 3.3 ( R − 0.03 − VUf P ) , (1) Chicago, IL, USA).
TABLE 2. Anthropometric data and mean of monthly interdialytic weight gain at the beginning (week -12) and at the end
(week 0) of the control phase and after the intervention phase (week 12)
Control phase Control phase Intervention phase
(week -12) (week 0) (week 12)
Dry weight (kg) 57.2 ⫾ 13.2 56.8 ⫾ 12 56.4 ⫾ 12.7*
Body mass index (kg/m2) 22.5 ⫾ 4.8 22.4 ⫾ 4.8 22.2 ⫾ 4.6*
Mean of monthly interdialytic weight gain (kg) 2.4 ⫾ 0.9 2.3 ⫾ 0.9 2.5 ⫾ 0.9
With all patients considered, the adherence to the from 147.5 ⫾ 23.7 mm Hg to 150.4 ⫾ 23.9 mm Hg,
exercise training was 81.36%. and DBP increased from 89.4 ⫾ 13.8 mm Hg to
In the first week of the intervention phase, the 93.2 ⫾ 15.4 mm Hg.
mean time of three sessions of aerobic exercise We observed a significant reduction in the 24-h
(warm-up and conditioning) of the 14 patients was blood pressure levels at the completion of the exer-
21.3 ⫾ 9.2 min, which increased gradually through- cise training compared with the end of the control
out the study, reaching 33 ⫾ 4.2 min at the end of phase. Thus, the 24-h SBP dropped from 150.6 ⫾
12 weeks (P < 0.05). Except for two episodes of 18.4 mm Hg to 143.5 ⫾ 14.7 mm Hg, and DBP
hypotension in one patient following exercise, we did dropped from 94.6 ⫾ 10.5 mm Hg to 91.4 ⫾ 9.7 mm
not observe any clinical complications during the Hg (P < 0.05, respectively). During the sleep period,
study. patients experienced a statistically significant reduc-
tion of SBP from 150.4 ⫾ 23.9 mm Hg to 140.2 ⫾
19.4 mm Hg, and of DBP from 93.2 ⫾ 15.4 mm Hg
Physical functioning to 87.9 ⫾ 14.3 mm Hg (Fig. 2).
At the beginning of the control phase (week -12), Finally, at the end of the intervention phase, we
the 6MWT distance was 504.6 ⫾ 99.1 m, and the per- observed a significant reduction of 12 mm Hg and
ceived exertion according to the Borg scale was 5 mm Hg in SBP and DBP 24-h blood pressure,
13.4 ⫾ 2.1. At the end of the control phase (week 0), respectively, when compared to the beginning of the
the 6MWT distance increased slightly and nonsignifi- control phase.
cantly to 508.7 ⫾ 91.9 m, while perceived exertion Of particular interest is the fact that this drop in
decreased to 12.1 ⫾ 1.5. However, upon the comple- blood pressure occurred despite maintaining the
tion of the intervention phase (week 12), 6MWT dis- initial dosages and types of antihypertensive medica-
tance increased significantly to 554.9 ⫾ 105.8 m. In tions for nine patients, the reduction of the medica-
this phase, the perceived exertion was 11.9 ⫾ 1.1, sig- tions for one patient, and the withdrawal of all the
nificantly lower than the values of the control phase medications for another patient.
(P < 0.05).
Quality of life
As can be seen in Table 3, after the control phase,
Blood pressure
seven of the eight dimensions of the SF-36 question-
At the beginning of the control phase, 12 of the 14
naire showed nonsignificant increases. At the end of
patients were hypertensive, and 11 were on antihy-
the intervention phase, physical functioning, social
pertensive medications including combinations of
functioning, and mental health dimensions all had
three or more drugs. The most frequently prescribed
increased significantly in comparison with the begin-
antihypertensive medications were b-blockers,
ning of the control phase.
angiotensin-converting enzyme inhibitors, AT1-
receptor blockers, centrally acting adrenergic,
calcium channel blockers, and diuretics. After the Laboratory data
control phase, blood pressure was not changed. In Table 4 shows the laboratory data before and after
24-h monitoring, SBP decreased from 155.4 ⫾ the control phase and after the intervention phase.As
22.1 mm Hg to 150.6 ⫾ 18.4 mm Hg, and DBP we can see, during the control phase, no major alter-
decreased from 96.4 ⫾ 12.7 mm Hg to 94.6 ⫾ ations were observed, with the exception of Kt/V,
10.5 mm Hg. During sleep period, SBP increased which was significantly elevated as compared with
A B
200 200
180 180
* **
SBP DBP SBP DBP SBP DBP SBP DBP SBP DBP SBP DBP
Week – 12 Week 0 Week 12 Week – 12 Week 0 Week 12
Control phase Intervention phase Control phase Intervention phase
FIG. 2. SBP values and DBP values obtained by the 24-h ambulatory blood pressure monitoring (A) and during the sleep period (B) at
the beginning (week -12) and at the end (week 0) of the control phase and after the intervention phase (week 12). *P < 0.05 compared
with week -12 and **P < 0.05 compared with week 0 by general linear model repeated measures analysis of variance and least significant
difference post hoc test.
the beginning of this phase (P < 0.05). However, at increased physical functioning, contributed to blood
the end of the intervention phase, we observed an pressure control, and improved several quality of life
additional increase in Kt/V associated with signifi- domains.
cant increases in hemoglobin, LDL, and triglycerides, Patients on HD have a considerable loss of physi-
as well as a significant reduction in creatinine. Fur- cal functioning that reaches 64% of peak oxygen
thermore, it is interesting to note that the increase in uptake (VO2 peak) when compared with healthy, sed-
hemoglobin was accompanied by a nonsignificant entary individuals of the same age group (4).The gold
reduction in weekly total dose of erythropoietin and standard test for evaluation of physical functioning is
in the monthly dose of intravenous iron. the cardiopulmonary test, which provides identifica-
tion of VO2 peak. However, the low tolerability and
the need for special and high cost equipment, makes
DISCUSSION
this test less used in the clinical setting (8,12).
In the present study, the supervised aerobic exer- However, the 6MWT used in our study is one of the
cise training during HD sessions for 12 weeks most utilized tests in the literature (7,8,12–15). This
TABLE 4. Laboratory data, weekly dosage of erythropoietin and monthly dose of intravenous iron at the beginning
(week -12) and at the end (week 0) of the control phase and after the intervention phase (week 12)
Control phase Control phase Intervention phase
Variable (week -12) (week 0) (week 12)
Hemoglobin (g/dL) 10.8 ⫾ 1.7 10.8 ⫾ 1.2 11.6 ⫾ 0.8**
Kt/V 1.2 ⫾ 0.5 1.5 ⫾ 0.2* 1.7 ⫾ 0.4*
Creatinine (mg/dL) 10.7 ⫾ 2.5 11.0 ⫾ 1.7 10.3 ⫾ 1.9**
Phosphorous (mg/dL) 5.7 ⫾ 1.4 5.6 ⫾ 1.1 5.3 ⫾ 0.8
Potassium (mEq/L) 5.0 ⫾ 0.7 4.9 ⫾ 0.5 5.2 ⫾ 0.6
Calcium (mg/dL) 9.1 ⫾ 1.3 9.3 ⫾ 1.3 9.5 ⫾ 0.9
Albumin (g/dL) 4.0 ⫾ 0.2 3.9 ⫾ 0.4 3.9 ⫾ 0.6
Total cholesterol (mg/dL) 152.5 ⫾ 38.5 160.2 ⫾ 48.0 170.1 ⫾ 46.8
HDL (mg/dL) 45.9 ⫾ 19.1 45.1 ⫾ 18.5 45.4 ⫾ 19.0
LDL (mg/dL) 86.2 ⫾ 30.0 95.8 ⫾ 37.9 104.4 ⫾ 28.7*
Triglyceride (mg/dL) 102.6 ⫾ 43.5 96.6 ⫾ 35.2 127.0 ⫾ 54.6**
EPO dose (U/week) 6571.4 ⫾ 3936.3 7000.0 ⫾ 2000.0 6214.3 ⫾ 2516.9
IV iron (mg/month) 600 ⫾ 415.1 514.3 ⫾ 441.8 385.7 ⫾ 411.1
test has several benefits: it is easy to apply, less costly, despite the increase in the 6MWT distance. Further-
less time consuming, and is very representative of the more, the increase of 35.5% in the time of aerobic
activities of daily life (8,12). Its efficiency has been exercise observed at the end of the study reinforces
confirmed in patients with chronic pulmonary the benefits of the exercise training in improving
obstructive disease and chronic heart failure (12). physical functioning. Similar data have been seen by
Corroborating this, in a previous study with 16 others in patients with ESRD (18,19).
patients on HD, we showed a positive and statistically It is well known that hypertension is highly preva-
significant correlation between the 6MWT distance lent in patients on HD, being present in up to 80% of
(516 ⫾ 88.8 m) and VO2 peak (20.5 ⫾ 4.9 mL/kg/ this population (3). Accordingly, in our study, 11
min) obtained in a cardiopulmonary test (R = 0.78) (87.5%) patients were hypertensive, and most of
(16). Based on these results, 6MWT was used in the them were on three or more antihypertensive drugs.
present protocol to evaluate physical functioning in After the intervention phase, we observed a signifi-
patients on HD. cant reduction in blood pressure levels despite the
Among our patients, the mean 6MWT distance at maintenance of the same antihypertensive medica-
the beginning of the control phase was similar to that tions or even after reducing the quantity in one
found in patients with ESRD on HD studied by patient and withdrawing all the medications in the
Painter et al. (13), Headley et al. (14), and Parsons other patient. Although a reduction in dry weight is
et al. (15). At the end of the control phase in our associated with blood pressure reduction, the small
study, the 6MWT distance had increased only 0.8%. drop on body weight observed could not completely
However, after 12 weeks of the exercise training, explain this finding in our patients. However, the
6MWT distance had increased significantly, by 9% well-documented role of exercising in the blood pres-
when compared with that at the beginning of the sure control is in accordance with our findings and
control phase, indicating that the exercise increased reinforces the benefit of exercise training on blood
the physical functioning of the patients. Our results pressure control in patients with ESRD. Few authors
thus support previous reports of exercise in HD have used ABPM to evaluate the blood pressure
patients (15,17). For example, Parsons et al. (15) control after exercising. In a recent article published
showed in a study of 13 patients on HD that 20 weeks by Anderson et al. (20), patients on HD were submit-
of exercise training during dialysis was associated ted to aerobic exercise training for 6 months. Similar
with an increase of 14% in the distance in 6MWT. In to our data, at the end of the protocol, the authors
parallel with the increase in the distance covered observed a significant drop in blood pressure after
during the 6MWT, we observed an improvement on aerobic training. This data was confirmed in another
the perceived exertion in the 6MWT. As we showed, study by Miller et al. (19) that showed that exercise
after the intervention phase, the perceived exertion during HD decreases the need for antihypertensive
evaluated by the Borg scale decreased significantly medications.
Patients on HD have low scores of quality of life increase in appetite and dietetic factors. Further-
that are frequently related to hospitalization and more, we believe that the increase of triglycerides
death (6). In the present study, the increase in physi- (from 96.6 ⫾ 35.2 mg/dL to 127.0 ⫾ 54.6 mg/dL) is
cal functioning, reduction of blood pressure levels, instead related to the normal variability of this
and increase in hemoglobin levels were accompanied parameter, possibly associated with improvement in
by a significant improvement in quality of life. Even appetite. Some authors have shown intraindividual
before the intervention phase, we observed a slight variability in triglycerides dosages from 20 up to 30%
increase in seven of the eight dimensions of the ques- (27). Besides, our patients did not have any other
tionnaire that could be attributed to the effect of evidence of hypercatabolism such as anemia, low
attention intervention consisting of stretching exer- serum albumin levels, anorexia, or increase in plasma
cises in the control phase. However, after the inter- creatinine levels. Actually, after exercising training,
vention phase, we observed an additional increase in most of these parameters had improved.
the same dimensions, with statistical significance for An unexpected finding of this study was a mild,
physical functioning, social functioning, and mental although statistically significant, decrease of esti-
health. These findings have been seen by other mated dry weight at the end of the intervention
authors among patients with ESRD on HD submit- phase, which could indicate reduction of lean body
ted to exercise training and have been attributed to mass. However, if one considers some benefits such as
the reduction of anxiety and depression, improve- better blood pressure control, improvement of physi-
ment in well-being, self-esteem, and familial and cal functioning, and the increases in hemoglobin
social interaction (13,21,22). Therefore, we could levels and in Kt/V after exercising, this possibility
speculate that, in our patients, the improvement in does not seem to be relevant. Furthermore, the
quality of life might share the same mechanisms. estimate of dry weight in patients on regular HD
Regarding the laboratory data, the better control is an imprecise trial-and-error method and does
of anemia after the intervention phase associated not account for changes in nutritional status and lean
with a reduction in doses of erythropoietin and intra- body mass (28).
venous iron deserves special mention. This benefit One frequent concern in performing exercise
has been well described by Goldberg et al. (23) after during HD session is the possibility of complications.
exercise training in patients on HD. It is recognized that the HD process induces acute
At the end of the study protocol, patients pre- complications such as hypotension, muscular cramps,
sented a significant increase in Kt/V. This increase in arrhythmia, nausea, vomiting, and headaches, among
the Kt/V was observed at the end of the control others, which could be magnified by exercising (29).
phase as well as in the intervention phase. We In our population, however, only one patient pre-
believe that the improvement of the Kt/V in the sented two episodes of hypotension after exercising.
control phase could be related to a better compli- This patient was diabetic and possibly had autonomic
ance of the patients with dialysis time, which we fre- dysfunction, which could have contributed to
quently stimulated. This is in agreement with the the event (29). No other acute complication was
findings of Fourtounas et al. (24), who showed that observed during the study protocol.
the most common cause of lower-than-expected There are a few limitations to this study. One of
Kt/V was noncompliance with dialysis time due to them is the absence of the control group. However,
patients’ request of premature termination of dialy- the comparisons were carried out in the same group
sis sessions. After the intervention phase, the addi- of patients, both before (control phase) and after
tional increase in Kt/V was attributed not only to the exercise training phase, which attenuates this
the compliance of the patients with dialysis time but shortcoming. The other limitations are the short
also to an additional removal of urea and toxins duration of the exercise training and the small sample
from the vascular compartment probably due to an size, which does not allow us to generalize our find-
increase in systemic and muscular blood flow asso- ings to the whole population of ESRD patients.
ciated with exercise, a finding previously reported by
others (15,25).
CONCLUSION
It is known that aerobic exercise improves the lipid
profile in various populations including patients with Aerobic exercise training performed during HD
ESRD on HD (23,26). However, contrary to these sessions for 12 weeks increased physical functioning,
data, our results showed an increase in triglycerides reduced blood pressure levels, and contributed to the
and in LDL cholesterol. We could speculate that this control of anemia and quality of life in patients with
change was associated with other variables such as ESRD.
Acknowledgments: We thank the nursing and 14. Headley S, Germain M, Mailloux P, et al. Resistance training
improves strength and functional measures in patients with
medical staff at the Nephrology Unit of the Univer- end-stage renal disease. Am J Kidney Dis 2002;40:355–64.
sity Hospital of the Federal University of Juiz de 15. Parsons TL, Toffelmire EB, King-Vanvlack CE. Exercise train-
Fora for their support during this study. This work ing during hemodialysis improves dialysis efficacy and physical
performance. Arch Phys Med Rehabil 2006;87:680–7.
has been supported by the IMEPEN Foundation 16. Reboredo MM, Henrique DMN, Faria RS, Bergamini BC,
and CAPES (Coordenação de Aperfeiçoamento de Bastos MG, Paula RB. Correlação entre a distância obtida no
Pessoal de Nível Superior). teste de caminhada de seis minutos e o pico de consumo de
oxigênio em pacientes portadores de doença renal crônica em
hemodiálise. [Correlation between the distance covered in the
six-minute walk test with peak oxygen uptake in end-stage
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